Accident Investigation (2)

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  • 1. ACCIDENT INVESTIGATION A Total Hazard Control System.
  • 2. PURPOSE To Complete The Aspects Of A Total Hazard Control System.
  • 3.  
  • 4.  
  • 5. THESE ASPECTS ARE:
    • Hazard analysis
    • Inspection
    • Measurement
    • Accident investigation
  • 6. WHY?
    • Determine cause(s)
    • Uncover indirect accident cause
    • Document facts
    • Provide information of cost
    • Promote safety
  • 7. WHO?
    • Supervisor
    • Foreman
    • Safety and health professional
    • Special committee
    • Company safety committee
  • 8. WHAT?
    • What was the person doing?
    • What was the person’s normal duties? Or what was different?
    • What were others doing at the time?
    • What was the proper equipment the person should be using?
    • What procedures were being followed?
  • 9.
    • Was the process/task new?
    • Was the person being supervised?
    • What training did the person have?
    • What was the location?
    • What short-term actions taken to prevent it?
    • What long-term actions need to be taken, and if previous corrective actions taken or recommendation followed?
  • 10. TYPES
    • Failure Mode and Effect Analysis (FMEA)
    • OPERATONS Hazard Analysis (OHA)
    • Risk Tree aka Management Oversight & Risk Tree analysis (MORT)
    • 4M Man, Machine, Media, Management
    • Cost Effectiveness Analysis
  • 11. The C&E diagram is also known as the fishbone diagram because it was drawn to resemble the skeleton of a fish, with the main causal categories drawn as "bones" attached to the spine of the fish, as shown below.
  • 12. Cause & effect diagrams can also be drawn as tree diagrams, resembling a tree turned on its side. From a single outcome or trunk, branches extend that represent major categories of inputs or causes that create that single outcome. These large branches then lead to smaller and smaller branches of causes all the way down to twigs at the ends. The tree structure has an advantage over the fishbone-style diagram. As a fishbone diagram becomes more and more complex, it becomes difficult to find and compare items that are the same distance from the effect because they are dispersed over the diagram. With the tree structure, all items on the same causal level are aligned vertically.
  • 13.  
  • 14. To successfully build a cause and effect diagram:
    • Be sure everyone agrees on the effect or problem statement before beginning.
    • Be succinct.
    • For each node, think what could be its causes. Add them to the tree.
    • Pursue each line of causality back to its root cause.
    • Consider grafting relatively empty branches onto others.
    • Consider splitting up overcrowded branches.
    • Consider which root causes are most likely to merit further investigation.
  • 15. DATA COLLECTION
  • 16. ANALYSIS OF THE FACTS
  • 17. CORRECTIVE ACTION PLANNING
    • Cost
    • Time
    • Human Element
  • 18. RESOURCES AVAILABLE
    • OSHA Publications
    • TWCC Publications
    • National Safety Council Publications
    • OSHCON
      • 1(800) 687-7080
        • www.oshcon.twcc.state.tx.us